Utilization Review Nurse - RN (WHWC)

Position Summary

The Utilization Review Nurse (RN) supports care coordination by reviewing clinical documentation, evaluating medical necessity, and facilitating communication between providers and care teams to ensure appropriate, timely, and patient-centered care.

Scope and Impact

This role impacts patient outcomes across the care continuum by ensuring appropriate utilization of healthcare services, supporting referral processes, and promoting adherence to care coordination and patient-centered medical home principles.

Decision Making Authority

Exercises clinical judgment in reviewing patient records, determining appropriateness of care, and identifying next steps within established guidelines and protocols. Escalates complex cases as needed.

Interactions / Working Relationships

• Internal: Care Coordination team (RN/LVN/MA), Patient Referral Coordinators, primary care providers
• External: Specialty providers, physician offices, multidisciplinary care teams
• Frequent communication with clinics and external partners to coordinate patient care and referrals

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Essential Duties and Responsibilities

• 30% Review patient records, referral notes, and treatment plans to determine medical necessity and appropriate level of care
• 15% Coordinate with specialty providers and internal teams to ensure continuity of care and timely processing of referrals
• 10% Enter, maintain, and document clinical information in electronic health record (EHR) and medical management systems
• 10% Process pre-authorizations and diagnostic orders in collaboration with Patient Referral Coordinators
• 10% Communicate patient status updates, appointment scheduling, and follow-up care with clinics and providers
• 10% Provide patient and family education regarding conditions, treatments, and care plans
• 5% Ensure compliance with HIPAA regulations and organizational policies
• 5% Promote patient-centered medical home principles and support care coordination initiatives
• 5% Participate in multidisciplinary collaboration and case consultation
• Other: Perform additional duties as assigned

Supervisory or Leadership Responsibilities

This position does not supervise others.

Qualifications

• Minimum Qualifications (Required)
• Education: Graduate of an accredited nursing program
• Licenses/Certifications: Active Registered Nurse (RN) license in the State of Texas
• Experience: Minimum of three (3) years of RN experience

Preferred Qualifications

• Bachelor of Science in Nursing (BSN)
• Experience in case management, care coordination, or acute care settings
• Bilingual (English/Spanish) proficiency

Knowledge, Skills, and Abilities (KSAs)

• Strong clinical assessment and critical thinking skills
• Effective communication and interpersonal skills
• Ability to multitask and manage multiple referrals simultaneously
• Strong organizational skills and attention to detail
• Knowledge of medical terminology and clinical documentation standards
• Ability to work independently and collaboratively in a fast-paced environment

Language Skills

• Required: English proficiency
• Preferred: Spanish proficiency

Technology and Tools

• Electronic Health Records (EHR) systems
• Medical management/referral systems
• Microsoft Office Suite (Word, Excel, Outlook, PowerPoint)

Work Environment and Physical Demands

• Work setting: Office/clinical environment with potential patient interaction
• Travel: May require local travel; valid driver's license and insurance required
• Physical demands: Standing, walking, bending, sitting for extended periods; ability to lift up to 25 lbs